Chart documentation quality and its relationship to the validity of administrative data discharge records
Chart documentation quality and its relationship to the validity of administrative data discharge records
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DOI：
10.1177/1460458210364784
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发表时间：
2010-06-01
影响因子：
3
通讯作者：
Quan, Hude
中科院分区：
文献类型：
--
作者：
So, Lawrence;Beck, Cynthia A.;Quan, Hude
管理数据的有效性可能容易受到医生记录病历的影响。本研究的目的是确定图表文件质量和行政数据的有效性之间的关系。对接受颈动脉内膜切除术的患者的图表进行重新提取，并对文件质量进行评级。根据患者、医生和医院变量以及管理和重新提取数据之间的一致性，比较记录不良和记录良好的图表。在审查的2061份图表中，42.6%被评为记录良好。在17家医院中，记录良好的图表比例从14.6%到87.5%不等，但患者特征没有显著差异。记录良好的图表的Kappa统计量通常高于记录不佳的图表，但在合并症之间存在差异。总之，记录不良的医院图表往往被翻译成无效的管理数据，这减少了医疗保健提供者之间的临床信息的沟通。
The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.